Monday, March 30, 2009

Just Do It

My son and I just returned from a 4 day mountain biking trip in Canyonlands National Park, just outside of Moab. This was our fourth trip with Western Spirit Cycling, and I have to say once again that this is the best experience I have ever had with my son. The guides are fun, funny, great cooks, unbelievable riders, helpful, and genuinely great people; in four trips, I have ridden and camped with 12 different Western Spirit guides, and they have all been gems. Our trip this year was a bit windy and chilly (in the teens one night), but the scenery was beautiful.

We rode the White Rim Trail, which initially runs along the Colorado River, and then winds along the Green River. My son is now 15, and can absolutely kick my rear on a bike. Here is one of the few times he was within my sights during the day.

We did get caught in a spot of nasty weather -- cold winds, a touch of snow, and a few pretty chilly nights. But it was never bad enough to make this anything less than a great time.

I cannot recommend this company highly enough. While I think it's great to do with my son, by no means are all of their trips designed to be for families only.

So, if you are willing to sweat a bit on vacation, give 'em a call.

Tuesday, March 24, 2009

Canary, Meet a Possible Coal Mine Air Shaft

GruntDoc recently posted about how he feels the EDs in this country are similar to lobsters, slowly cooking while to death while they think they are doing reasonably OK. The same could be said for a variety of specialties in medicine, where the poisonous trifecta of poor insight of our governing bodies, the insidious nature of reimbursement decreases brought on by the RBRVS system (thanks, AMA!), and government intervention has generated unintended outcomes in patient care and physician behavior. Add to that the cost of "CYA medicine" (yes, Matt, it does happen) generated by the fear of being sued, and you've got a swell recipe for boiled lobster.

But I've posted about this before, and certainly anyone connected with medical care can see that there are big challenges ahead for us. Peruse the most recent National Medical Resident Match Program Data, and compare it with historical data, and you'll get a sense of how few front line physicians there will be available in the future. There are not, however, a whole lotta big solutions on the horizon. Some folks are starting to get innovative in their thinking, however, and are starting to look beyond the knee-jerk response of "hire more physician extenders."

I spend a considerable amount of time in the hospital providing trauma coverage for our ED. This requires me to be physically here for a 24 hour stretch, in addition to my regular work as a general surgeon. It gets, to be honest, old. And I suspect that there will come a time when I will no longer provide trauma care, particularly if my income gets slashed by the socialists in Washington. There are many institutions in larger cities where there are trauma services that provide essentially nothing other than trauma care, because the volume of injured patients requires this. That, for me, would get really old.....and there really isn't an abundance of general surgeons who feel differently. As a result, there is already a shortage of dedicated trauma surgeons, and there will be a gradually growing deficit in the future.

Cue one innovative and interesting solution -- "Emergency Traumatologists as Partners in Trauma Care: The Future is Now." Brought to you courtesy of one of my old senior residents, now part of the Penn system. Here's the abstract:

Background Decreasing manpower available to care for trauma patients both in and out of the ICU has led to a number of proposed solutions, including increasing involvement of emergency medicine-trained physicians in the care of these patients. We performed a descriptive comparative study in an effort to define the role of fellowship-trained emergency medicine physicians as full-time traumatologists.

Study Design We performed a retrospective review of concurrent and prospectively collected data comparing process of care and outcomes for the resuscitative phase of trauma patients cared for by full-time fellowship-trained trauma surgeons (TS), a fellowship-trained emergency medicine physician (ET), and a first-year fellowship-trained trauma surgeon (TS1).

Patient age, Revised Trauma Score, and Injury Severity Score were similar between groups. Process of care, defined by transfusion of uncrossmatched blood, prevalence of hypotension in patients receiving uncrossmatched blood, time spent in the emergency department, frequency of ICU admission, severity of injury for ICU admission, and time between emergency department and operating room for patients requiring surgery, was equivalent between groups. Outcomes evaluated by mortality and length of stay in the hospital and ICU did not differ between groups, and provider group was not predictive of mortality in stepwise logistic regression.

These data suggest that emergency traumatologists can provide trauma care effectively within a defined scope of practice and may provide an effective solution to manpower issues confronting trauma centers.
Interesting. Innovative. But workable?

Let's look at the positives first. Evaluating all the data, the patients cared primarily for by the fellowship trained trauma surgeons and the fellowship trained emergency medicine physician were similar in characteristics, and had similar outcomes. In other words, the patients did as well regardless of which of the three physicians were caring for them.

However, we are talking primarily about patients with blunt trauma --- auto accidents, primarily. Those with penetrating injuries, while they can initially be assessed by a non-surgeon, will require surgical intervention. And the occasional blunt trauma patient also needs a laparotomy. From the article --
Clinical coverage grids were designed using the ET in appropriate areas and in compliance with PTSF/ACS (American College of Surgeons) guidelines for trauma center accreditation. So the ET could not provide independent in-house coverage for trauma unless supported by a surgeon.
Additionally, this retrospective study looked at the involvement of a single fellowship trained emergency medicine physician. It would be very unwise to therefore extrapolate this data to suggest that it is a workable model for most institutions. But it may be an alternative to the approach that has been suggested by the AAST and ABS:
...the American Board of Surgery has supported efforts on behalf of the American Association for the Surgery of Trauma to establish a curriculum in acute care surgery in the hope that redefining the content and spectrum of care provided by trauma surgeons might attract more residents to the specialty. It is too early to judge the effectiveness of these efforts, but as yet only two institutions have applied for accreditation for this fellowship. In addition, it is unclear how much this curriculum differs from the current practice of many trauma surgeons, because the requirement and opportunity to learn and apply operative skill sets derived from orthopaedics and neurosurgery are very limited.
Is the Penn approach a good solution? Perhaps, rather than being a solution for all, it is an indication that there is no single solution that will work for every institution. As the system as a whole struggles in the future with fewer physicians, each hospital is going to have to find a workable solution to fill their needs, whether in trauma surgery, OB, thoracic surgery, or medicine. As I have often said, the future of medicine is paved not with concrete, but quicksand, and knowing how quickly to keep moving in any particular direction is difficult. Finding the missing piece of each puzzle will require innovative thinking. Nice work, Dr. Grossman.

Sunday, March 22, 2009

Where are they?

My brother was recently in Houston, and decided to do what all old farts do when they are in places they used to live ---- look up old girlfriends!!! Actually, he drove by the house we last lived in there, and sent along a photo or two:

Though I last was inside the house in 6th grade, I'm pretty sure I could walk in the front door, take an immediate right, head up the stairs, and find 6 miles of Hot Wheels track in a large room on the second floor. My little brothers and I would set the track up to start on top of a bed, snake through the room, run down the stairs, and end on a the cars left a series of dents in the wall at the bottom of the stairs (Sorry, Mom. I hope the current owners have better luck with their kids).

My father planted the pine trees in the yard, and they have grown just as he had hoped. The weeping willow that was in the front yard was taken down some time ago, and the buckling sidewalks where we used to ride bikes looks to have been replaced. It seems as if I spent my entire childhood destroying decks of my parents' playing cards, clothespinning them so they would make noise while I cruised the neighborhood (Sorry, Mom).

At night, though, I got to see my future, or at least I thought I could. I'd read books like "20,000 Leagues Under the Sea" and "The Wind in the Willows," and think I could have great adventures. I'd watch SciFi shows like The Outer Limits, The Twilight Zone, and Night Gallery and think about all the cool things that would scare the willies out of me in the years ahead. But most of all, I'd watch Dino and the Golddiggers ---- that was going to be my real future!

Dean would swagger out from behind a curtain every Thursday night, carrying a martini, and spend an hour yukking it up with John Wayne, Frank Sinatra, Don Rickles, Lucille Ball, and whoever else was part of the Hollywood crowd at the time. I frankly don't remember much of that, other than the fact that he rarely got through a skit without barely contained laughter himself. What I do remember, however, are the Golddiggers surrounding him like a cloud of hot-looking angels. I remain convinced that before the show, they would check his tuxedo to make sure it looked sharp, and stirred the perfect martini just for him. It was the perfect image to send a 6th grade boy off to sleep.

My 6th grade mind became wholeheartedly set on the idea that I would grow up to be Dean Martin, and that every night I'd come home to a cold adult beverage and a harem of scantily clad women waiting for me. Really. Forget Cary Grant, Sinatra, or any of the current crop of stars --- Dino was the epitome of cool.

So, I've been wondering. The Outer limits has been recycled and repackaged. 20,000 Leagues Under the Sea has been made into yet another movie. Though not in name, Night Gallery themes can be found in myriad of TV shows and movies. The Twilight Zone has been revived more times than Resusci Annie. So, I've been wondering....I've got my martini glasses, olives, and gin, so...

when do I get my Golddiggers?

SWIMBO, I suppose, would not approve. But maybe she's waiting for Dino, martini in hand.

Tuesday, March 17, 2009

5 Steps to a Happier Healthcare System

Too many nights on call, too many weekends on call, too little sleep lately to blog coherently. Oh, I've tried, but get 2/3 of the way through a post and realize that what I have written makes about as much sense as a Jackson Pollack painting --- colorful, but impenetrable and eventually utterly meaningless to someone who spends any time looking at it. So, I'll try again.

Much ink has been spilled recently in the newspapers regarding "health care reform," and many more pixels have burned brightly on news sites and blogs about the same. Since nobody in Washington gives a rat's rear end about what I have to say about the subject, I'll offer my prescription for health care reform right here. It's a 5 step program, easy to implement, but impossible for the politicians and lobbyists to swallow.

Step 1. Uncouple health insurance from employment. Basically, allow folks the same degree of freedom in selecting a health insurance product that they enjoy in selecting life, disability, and auto insurance. Ever notice how all of those GEICO and Progressive auto insurance ads tout not only better pricing, but better service as well? That's the cool thing about a competitive marketplace --- it tends to keep prices reasonable and allows an even playing field.

How to do this? Actually, despite the protestations from the Obamanistas, Sen. McCain's idea of allowing a tax credit for individuals purchasing their own insurance, while taxing the benefits of employer-provided health insurance was a reasonable step in this direction. I would prefer to simply not tax income used to purchase health insurance, regardless of who is footing the bill.

Why won't this be allowed by the folks in Washington? As is pretty obvious, the folks currently running the world's biggest money wasting entity simply want to find ways to get more of your hard-earned money, including taxing your health care benefits (but without the tax credit). Gotta pay for that "stimulus," you know.

Step 2. Eliminate state-specific health care requirements, and allow folks the freedom to choose health insurance from providers across the country. What many consumers don't know is that each state sets the requirements for what a health insurance plan must cover. For example, in my state, chiropractic care is mandated to be covered. That's sort of like requiring coverage for readings by Miss Cleo, in my opinion, but that's beside the point --- I, along with every other Colorado resident must pay for chiropractic care when paying for health insurance. And I am not allowed to call bullshit "Pelosi" on that and purchase coverage from an insurer in a neighboring state that doesn't have this requirement.

How to accomplish this? I think that most Americans can agree on a basic set of requirements of a health insurance plan, which could serve as a basic starting point for consumers to compare plans and coverage options that could be done more in an a la carte fashion. You want chiropractic coverage, aromatherapy, and massage therapy? Great, here's the pricing schedule. To my mind, this would be the only place where the feds would set policy, and eliminate the ability of lobbyists to get state regulators to insert a host of costly add-ons to plans that consumers don't want.

Why won't this be allowed by the folks in Washington? If those self-serving idjuts won't even allow a la carte pricing for cable TV, do you think they would do it for health care? Besides, the lobbyists for folks wanting their bailiwick to be fully covered would be out in force, so achieving a consensus on a basic level of coverage would be damn near impossible. Given the stinking pile of Pelosi that passed as a "stimulus package," we would probably end up with "basic" coverage that would be far more expensive than what we have now. Even so, I can dream, can't I?

Step 3. Tort Reform. This is a concept near and dear to my heart....and should be to anyone who runs a business. Tort reform would positively impact every single industry in the country, not just health care, with significant savings. Loads and loads of information here.

How to accomplish this? Take Shakespeare's suggestion (Henry VI -- Act IV, Scene II).

Why won't this be allowed by the folks in Washington? They are all lawyers, and most importantly the party currently in power owes a tremendous debt to the trial lawyer lobby. This will never, ever happen in our current political climate.

Step 4. Establish a system of health courts. Just because I think tort reform is desperately necessary for the U.S., I do not think that folks should be unable to access the legal system if they have been truly wronged, whether in the health care system or due to gross negligence in another field. But in the current medical malpractice environment, the only winners are the attorneys.

How to accomplish this? Once again, this would require the full participation and engagement of legislators willing to ignore the trial lawyer lobby.

Why won't this be allowed by the folks in Washington? See the answer in question 3. Ain't gonna happen, no matter how many good folks support the idea.

Step 5. Make me king. "Aggravated DocSurg, Lord of all that is Good and Reasonable, Emperor for Life." Has a nice ring to it, don't you think? That way, I can make sure that this is all accomplished with a minimal amount of bloodshed fuss.

OK, that's not realistic, at least not until I become better armed (time to visit Dragon Man). Actually, step 5 is to tackle the many headed hydra known as Medicare. There is simply not enough money lying around in the pockets of "the rich" to satisfy this cash sucking beast, but there are some concrete steps that could be used to rein it in a bit:

  • Eliminate coverage for chiropractic care. I mean, really, what a waste of cash. We'd be as justified as having Medicare cover astrology as chiropractic care.
  • Allow physicians and hospitals to write off the difference between what Medicare pays and what they would otherwise expect to get paid for the same care. Everybody knows that there is cost shifting going on, and Medicare simply does not cover the costs of providing care to most patients. Why shouldn't I be able to write that off as bad debt or charity on my income taxes? This would immediately solve access problems for patients, particularly in primary care; it has gotten so bad that in my community I cannot find physicians willing to see Medicare patients in many instances.
  • Put the institution of ICD-10-CM on the back burner. Permanently. Coding for care is expensive and time consuming, and the next version of the international classification of diseases is an exponential increase in complexity for coding, with no benefit to payors, consumers, hospitals, or physicians.
  • Eliminate the "3 day" rule to get patients from the hospital into a nursing facility. This is frankly a silly rule that increases costs for all hospitals and for Medicare.
  • Eliminate the rule that prevents Medicare patient from being held overnight at an outpatient surgical facility. This, too, is a silly rule that increases the costs that Medicare and patients must expend to have procedures done.
  • Eliminate the bastard stepchild of Teddy Kennedy and the Balrog known as GPCI. There is no difference in a laparoscopic cholecystectomy done in Colorado as compared to New York, but the pay from Medicare is different based upon Geographic Practice Cost Indices, which are determined by a formula so poorly designed that it would make Einstein blush. It's a ridiculous abuse of the physicans participating in Medicare.
  • Allow seniors with enough of their own money to fully opt out of Medicare. While this is currently technically possible, it is pretty damn difficult to achieve, and because of the issues above is pretty damn expensive.
  • Last, but not least, mandate that all Congressmen and their families be placed into the Medicare system during their time in office and for five years after they leave office. That will eliminate a whole lotta political poppycock.

Pipe dreams? Sure. But heck, if I can dream of being emperor for life, at least I can dream of doing something good with the title.